Thursday, September 26, 2013

I somehow got blessed with two kids on opposite ends of the growth spectrum: Mikko through toddlerhood was a happy 150th percentile kind of guy, and I just let him keep on growing. He was barely eating any solid food before he was two, so I knew it would all even out, and it did. He'll always be a tall and hefty kid (around the 80th percentile now for both height and weight), but that's his body type.

See how sickly he is? Sad.

Then Alrik came along, and he's wee. His height is puzzling though not particularly worrisome: 33rd percentile. His dad and I are tall, so it's strange to have a shrimp. But his weight is off the charts, the other way. At 2 years and 4 months, his 23 pounds doesn't even register.

This is not only weird — it is a trifle concerning. He comes from a family of generally larger-than-average people with a few skinny minnies. So he could just be one of those recessives, right? But his naturopathic pediatrician is cautiously concerned, because here's how nutritional deficiencies can manifest:

First goes the weight, then the height, then the development.

In other words, the weight's already gone. He's already demonstrating that he's atypically short (genetically speaking). So is his developmental progress next?
Whenever I talk about this with other parents, I get the blithe reassurances I gave myself (and others) about Mikko: Every body is different. Somebody has to be on the small (or large) side! You don't have to be average to be normal. If he's meeting developmental milestones, he's fine. As long as he seems healthy, he probably is.

I'd say I have about 90% confidence that all the above is true for Alrik: that he's just a short, slight fellow who's perfectly healthy.

It's that 10% of uncertainty that's killing me.

What if he has an underlying health issue that I'm glibly ignoring? It makes me glad we had him tested for cystic fibrosis in his newborn heel stick, for instance, because I've lost friends to that wasting and respiratory disease, and that makes me jumpy. I've been looking at photosoftoddlerswithceliac and comforting myself that although his legs and arms are skinny, they're not that spindly, and his toddler gut just looks like a normal pooch, not a gas-filled starving-child's potbelly. But what if?

When we saw the pediatrician last year, she wanted us to put Alrik onto a formula of whole cow's milk, almond milk, carrot juice, and oil. I thought this was very odd. I really couldn't see how drinking such a mixture would be better than continuing to breastfeed — and wouldn't pushing that on him limit and replace his nursing sessions? Breastmilk is fattier and more caloric than whole cow's milk, and much fattier than almond milk and carrot juice. It has more nutrients than all of those liquids. I do give him cod liver oil as a supplement, however, since on a spoon seems a more reasonable delivery method to me than mixed in with milk. (Blech! For my part, I can't stand the fish breath it gives him, but he laps it right up.)

Based on my own research into how people gain weight, I understand that it's the amount and type of carbohydrates we load into our bodies and how it affects our blood sugars. So it doesn't make sense to me that people (including the ped) say to sneak avocado or peanut butter or oil into everything — dietary fat intake isn't what makes people fat. At the same time, I feel awkward emphasizing or feeling great about his scarfing down French fries and potato chips. (Yea … um … weight gain?)

So we emphasize nutrient-dense foods whenever possible, present a variety of options, remind him to eat (because he does get distracted easily), supplement with oil and whole-foods multivitamins, and continue the breastfeeding. I don't make food into a battle, and I don't push him to eat past what his hunger is telling him, though I do frequently offer bites when I notice his interest flagging. He's not what I'd consider a picky eater (at least compared with his older brother!), so he willingly eats a wide variety of food, though the amounts vary — some days, a plateful, and some days, a couple bites and he's off. It seems like we're doing things (mostly) "right" — but he's still small.

He also, by the by, seems incredibly healthy. He rarely gets (only minor) illnesses. His stools (oh, you know you wanted to find out!) seem normal to me — passed easily and regularly. (Wait — you didn't want to know? My bad.) Energy-wise, he never sits down and never stops moving. He's constantly doing his Power Rangers moves (highly entertaining) and racing after the kitties and helping out around the house (anything at all you're doing is fair game). He also still naps for several hours and sleeps fairly well through the night. (Fairly well. He is a cosleeping, breastfeeding toddler, after all.)

Developmentally, he talks really well for a 2-year-old, based on my experience (both in vocabulary and clarity), and he understands both German and English. He mostly speaks English but can break out some German if the occasion calls for it. He's learned a lot of sign language, though I'll admit his verbal abilities have made us deemphasize signing with him. He counts to eleven, which surprised us, since we're neglectful parents who leave our second born to figure out everything on his own. (Heh heh.) He is openly affectionate and happy, participates in imaginative play, and interacts well with other people (if we acknowledge he's a two-year-old, ha). He has good balance and gross motor control (he's got a wicked throwing arm) and is getting more and more dexterous with fine motor control. I say all this not to brag (as if — weird that sometimes it can seem braggy to describe what your child does) — for instance, Mikko was much less advanced in all these categories at the same age but caught up. I'm just saying, there's nothing developmentally that makes me worry: He's sick, and it's affecting his development!

Some hard data below. Seriously, note what terrible parents we are with the second born — so many months we didn't bother to measure! Oh, noes!

Mikko's height chart, 0-24 months, and his weight chart — he broke it. He was actually above the chart.

So: What to do? Ignore it? Get him tested for something — but what? (Possible medical causes of "failure to thrive" include GERD, liver disease, metabolic disorders, thyroid disorders, type 1 diabetes, CF, and celiac.) Do a trial elimination diet to see if there's something he should or shouldn't be eating?

As far as that last one goes — oy. Sam and I eat grain-free, and we keep a mostly grain-free house. However, the boys are very much not on board with this plan, so they eat grains outside the house. Mikko's first thought on rising is, "Where can I get grains today?" I kid you not. I keep floating the idea of having the kids be at least gluten-free for awhile so I can see if it helps Alrik's growth at all, and no one's having it. I think we'd need a confirmed diagnosis of something dire to spur the family as a whole onto a new eating path.

It's (past) time for his two-year checkup, and I keep hesitating about going back to the naturopathic pediatrician. For one thing, I feel sheepish we didn't actually give the weird milk-juice formula a go, even though I disagreed with it philosophically and nutritionally. For another, I just really hate going to the doctor. I pretty much always emerge feeling like visiting was a colossal waste of my time and money. I'm sure having my dear child jabbed and poked with needles and who knows what else if we decide to get him extensively tested will ultimately result in feelings of regret.

Unless: Unless there is something wrong. And then I'd feel regretful at some other time, if we find out down the road that there was an underlying illness we were closing our eyes to. Maybe it's when he's 5'4" as an adult that he'll read us the riot act for not acting sooner. Didn't we see how skinny he was? Didn't we feel concerned that his height was so far below the norm for our family?

What would you do? Do you have experience with mini-sized children? Was any course of action recommended, and did anything particularly help spur growth? Were there any complications you collided with or successfully avoided?

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comments:

Our son Robert, about a month older than Alrik, is a little guy too. We haven't weighed/measured in a while, so I don't know his current percentile, but it was down near the bottom for weight last time we checked. He can still fit into some 18-month clothes, and definitely into a 2T. The doctor hasn't recommended anything so far. I think he is okay. He is a picky eater and is no longer breastfeeding, but loves whole raw milk. I'm sure it's something we'll revisit at our next doctor's appointment, but I feel the same about going to the doctor. Although we really like our doctor, the visit is usually rather pointless except to find out nothing is wrong and to be on the books just in case we need a Rx called in later or something. I think I probably would wait on testing as long as my child seemed healthy and happy.

When my firstborn was 6mos old she stopped gaining weight. By 1yr she had only gained an additional 1/2lb. She was still growing in height albeit at a much slower rate than when she was under 6mos old. At that point our doctor decided that while she seemed fine in every other way, we should do some tests just to make sure. Everything came back fine and his response was to keep feeding her a wide variety of foods and to keep breastfeeding her. At 2 she was about 22lbs which isn't even on the charts and now at 7 she's 53lbs which is right in the middle of the chart. When my younger child was born he was about the same birth weight and gained at about the same rate as my daughter had. When at 6mos he stopped gaining our doctor just shrugged and said that this seemed to be the growth pattern for my babies and told me to make sure I was getting adequate fats and general nutrition and to keep breastfeeding as long as possible. He is now 5 and in the 90th percentile in both weight at height for his age. Even if they hadn't started catching up I don't think we would have worried much if they were growing a little bit even if it was slow. If he were mine, unless his growth had stalled completely, I think I'd be watchful but not reactive.

My oldest, Jill, was born in the 95th percentile and quit growing taller by the time we got to her 1 year check up. She dropped off the charts at the bottom. The doctor mentioned failure to thrive, dwarfism, and a thousand other things... but ultimately we decided to wait and see if she'd start growing again. She's 5 now and still under the 5th percentile, but she's continued to grow steadily. There still *could* be something wrong with her, but there's really no way to tell without having a bunch of tests run. I didn't want to put her through a bunch of blood draws and other random testing. She's mentally, intellectually, and emotionally fine... just short. I worry about it from time to time and it's been a motivating factor in our recent diet changes. (Giving up gluten, about to give up dairy)

tl;dr version: you aren't alone and as long as he keeps growing, he's still getting the things he needs to grow.

I can relate to this very much right now and have been having many of the same concerns over the past few weeks/months. Our daughter is 20 months old and 18lbs... actually down to closer to 17 1/2 this week due to a week long illness with no eating. Her weight / eating are our biggest concern and something we worry about every single day. In our case, I do think eating is her problem as she really doesn't like food (although we try EVERYTHING). But still trying to decide about tests at the moment. I suppose it would be best just to know right? Then if all tests come back okay, you know it is either food in our case, or just his body type in your case. Sorry you are dealing with these worries. I know how tough it is :( Hang in there!

Obviously I'm not a doctor but I look at it mathematically. Mikko is huge, Arlik is small, so they make up an average. That's over-simplified, sure, but it's the same for everything.

(I'm getting major deja vu here - Did you blog about this before? And did I comment the same thing? Anyways...)

Again, not a doctor, but Arlik looks pretty damn happy and healthy to me. Also, did you ever worry about Mikko? I was always proud that Sebastian was so big just being breastfed (and may have been a bit too braggy about it - I needed everyone to know that his size was all from me!) but as he got older and into solids, I did find myself worrying that he was overweight. Pretty normal to worry either way.

Indeed, "The guilt and responsibility of the mother." Not to scare you further, but from my own experience: I forget how tiny Spencer is compared to typical children. So... you could add genetic disorder to the list, but here's what I'm thinking...

OK, actually, I think I'd just debate the same as you have. No signs of any health concerns, so I'd tend to think I shouldn't worry. But, like you, I'd worry I as overlooking something. I'm usually unafraid to confront medical personnel when it comes to offering treatments I don't like, but I can understand your hesitance to take him in... and get a "talking to."

Honestly, if his height AND weight are low... it makes me think maybe he's just small. I mean, it might be different if he were TALL and underweight or whatever. It seems reassuring that he is at generally the same percentage on both charts, right?

Spencer, btw, is 75th percentile (on Down syndrome charts) for height and 50th percentile for weight. Do you have recordings of head circumference, too?

I have 3 kiddos that are all on the small side. My husband, however is 2 inches shorter than me at 5"4". He is Italian and his mom and sister are both around 5 feet so I just try to accept that I have small kids. I say try because I still often worry that there is something wrong, maybe my milk wasn't fatty enough, maybe I am not feeding them enough or the right foods, or do they have worms?, etc. There is something in our culture that really values babies at the "top of the charts" I seem to find it more among beastfeeding moms as well, like "look at what my breast milk did" Kind of frustrating for moms of small kids! Anyway, thanks for posting this and though I have no advice I can at least say that I empathize with your feelings!!

My kids are both small-ish, below 50%. When my son turned a year I had just a bit of concern because he had gone from a 90% newborn to 30% so I doubled down on making sure he was eating with the rest of the family at meal times in addition to nursing.

Anyway, if I had concerns like yours I would go ahead with a few tests so I could put my mind at ease (and so I could tell others with confidence that he really is just small, nothing wrong with him). Maybe just tell the doctor what you wrote in this post.

My kids are pretty average size wise (Joe is big though not as big as Mikko; Maggie is small but on the charts); but several of my friends have dealt with very small children, and I have a different perspective - I was a very very small child. I weighed 45 lbs in 4th grade. I was always the tiniest in my class. My husband was also a shrimp - 5' in 9th Grade. What's strange is that we both grew up to be very normal sized people. So it does happen. I was teeny tiny from babyhood, just like Alrik, and I'm now 5'4", 130 lbs., very "normal" really. I was a late bloomer and didn't reach my full height until college. But I did keep growing.

As far as the general guilt and worry, I definitely feel you - as you know, we've spent a lot of time worrying about Joe's development and possible "issues" and blah de blah blah. The worry'll kill you. As time goes on, I'm realizing he is a bit of a quirky kid, and that's okay. I don't know if/when I'll stop worrying entirely, though. It's hard being a mom. It's always something!

Hi, I stumbled across your blog randomly. I'm in Canada and I also have a 2 year old. He is 2 years and 4 months and weighs 25 pounds, which by Canadian and world health organization growth charts is between 15th-30th percentile... Hardly off the charts. It sounds like your little one is doing fine :)

@Jenny: You've mentioned one of the benefits of a teeny one: getting to use clothes for longer! :) We're still in 18-month, too. He can actually fit just fine into 12-month pants, but they're too short — something I always seem to notice after we've already left the house…

@Heather in Oregon: That's interesting that you had two that did the same slow climb to the middle of the charts. I know my perspective is an odd one since I had my firstborn be the exact opposite of the second child, size-wise. Anyway, you're giving me some encouragement that Alrik might go up some on the charts — my little brother did (he was a very petite child and is now a tall and thin but healthy adult), so he's my genetic hope.

@Jessica: I'd love to try giving up gluten, just to see if it makes a difference. But how to get the rest of the family on board…? Anyway — thank you for your comment; glad we're not alone, and I hope your daughter is also as healthy (yet small) as she seems.

@Fiona: That's kind of what I'm leaning toward, too — have some tests, so we can know and not speculate. But then the actual ordeal of the tests — ugh. Anyway, hope your little one is all right and starts better eating. For what it's worth, my firstborn didn't start really swallowing food (he tasted before then but tended to chew and spit out) until he was close to 2 years. We just never worried about it since he was so big! So maybe your daughter will start eating more soon.

@Janine Fowler: Ha ha ha! I love the average theory. I know my husband's said something similar, so we might have had this convo before, but it still makes me laugh.

I never worried about Mikko. Like you, I was proud that breast milk was making all those adorable rolls and pudge. I do look back at pictures and think, "Oh, my good gosh, he was HUGE!" Ha. And, yes, now I keep an eye on him and fret that he might have struggles with his weight the way his father and I have. So you can't win, right?

But, yes, I love how Alrik looks. I love that he's obviously thriving, and I do get great pleasure and reassurance from that.

@Momma Jorje: Right, genetic disorder is another one, and some messaged me privately to say the same thing.

I love that you're thinking it through just like I do!

I dutifully took head circumference measurements with Mikko and then totally FAILED AS A MOTHER with Alrik, lol. I think I have a few, here and there, but I forget what percentiles he was. I should look — maybe that would put brain development fears somewhat to rest?

@Lacey: You've hit the nail on the head; there really is a lot of pride in having big babies (though it tapers off and reverses at some point, huh?). Weird. It definitely sounds like you can expect small kiddos, so that's reassuring at least! I've been reminding myself of the people in our family who are on the smaller side.

@Inder-ific: It's funny how growth spurts can happen, isn't it? I remember a boy on my brother's high school basketball team who was 5' nothing one year and then over 6' the next. I guess I just think it's so odd with Alrik because the rest of his immediate family is so much larger than average. I'm 5'9", for instance, and Sam's 6'0", and we're hefty as well. (Heh.)

Yes, I can see the parallels with your experiences with Joe. I've been thinking more and more about possible sensory issues with Mikko and whether we should have had those looked at, or whether it doesn't really matter if we're all coping ok. It's always a question — whether and when to intervene, and potentially feeling at fault no matter what you choose.

@Jenn: Thanks! Glad to know there are similar kidlets out there. According to that chart, my little guy is still below the 3rd percentile, which is "off the charts" according to most charts. It's kind of nice that that one includes a 0.1 percent line, actually, so that he can officially be ON a chart somewhere! :)

:), I also want to add that it can be really hard when your first kid is so different. My son was really strong/active from the start and crawled at 4 months. My little girl is 4 months now and barely lifts her head. It is so hard not to compare, and not to worry that there is something wrong. I feel your pain a little bit.

Oh, I understand what you are going through. My youngest daughter has always been very small. At one year old she was 15 pounds and was a whole thumb width below the growth charts that my family doctor uses. She has tracheomalacia and refused to eat anything at all until she was 1 1/2. She was tested for celiac, her esophagus was tested for abnormalities, she was poked and weighed constantly. We went to so many specialists and I was guilted for not weaning her and putting her on formula or cow's milk (sigh, when will doctors get an understanding of infant nutrition?), and I was told to use "tough love" to get her to eat "real food" (aka force feeding her).

I finally found a nutritionist who measured her using the WHO breastfeeding growth charts and she came out at 3rd %ile. She said that while she was quite small, she looked perfect for her body, she seemed "normal" for developmental markers and she would probably always be short and small. Now at 3 1/2 she doesn't look abnormally small, just really petite compared to her peers. I still worry sometimes (she can still wear the larger fitting 18 month old clothes now that she's toilet trained and no bulky diaper - they're just really short on her because her height has started taking off), but I think I will always have something to worry about.

I finally decided to stop going to doctors and stopped making appointments for all the specialists because all it was doing was making me sick with worry. It certainly wasn't making her grow at all. If I were to notice anything change with her size or development I would go back to my doctor and perhaps start the process again, but for now I am playing "wait and see".

I think it might be harder for boys to be small than girls. People comment on how cute my daughter looks, and I think it is because she seems older than she looks because of her size. People always seem to comment on big strong boys and how they are going to be a football player or whatever. I can see that this might be a challenge for your son. I have a friend with fraternal twin boys (in their teens now), and one of them is quite tiny, and doctors are trying to push steroids for his development. He wants to try them because he is the smallest on his hockey team and he gets teased a lot.

My two cents - listen to your worries and act upon them if they get too loud, but mostly listen to your gut and not worry too much about the doctor visits (do you feel comfortable not going to the next scheduled visit if it isn't "important"?). The constant testing and monitoring "just in case" can be a killer for stressed out mamas. I believe that we know in our gut when something is wrong.

Oh what beauties they both are! There is so much emphasis on the curve...but like any parenting issue we have to listen to our guts. Honestly it sounds like you want some more data but you are dreading the physical part of the testing. Do you know what the tests are? Maybe just start there. Also I have a friend whos daughter was in the same boat - healthy seeming, active, smart but so small. They were tipped off by a doc friend who heard her labored breathing while she slept and it turns out she wasn't getting enough oxygen. One surgery later and a huge growth spurt occured! Just a thought...Hugs to you, Mama!

How about finding a different pediatrician? Especially if you felt the advice you were given before was a bit specious, why not find someone you prefer and whose opinion you're more likely to trust.

My kids are on the small side, which isn't surprising as I'm 5'4 and their father is 5'9. My son, who lives on peanutbutter and air, has been solidly at the 50th percentile mark for all his years, and his sister, whose diet is more varied, is a petite 35th percentiler. So long as their height and weight are proportional and they continue to gain along their curve, my ped is not at all worried. Just for some more datapoints.

My daughter is a couple weeks older than Alrik. She was 8lbs 7 oz and 20 inches at birth. Since then, she has stayed solidly and precisely on the 50th percentile line for weight for her age...but she isn't quite 2.5 years old yet and she's on the 4 year old height chart. She is so tall people expect her to behave like a 4 year old. It's just how she is made. She is also super-busy and active like you describe Alrik. She still nurses at night while cosleeping.

We need to talk. I need to know how you're little baby is doing now. My daughter was born preemie on feb 2014. She was born 5lbs 9oz. Today at 22 month old she weights 22lbs and is 80th percentile in height. She was only 14lbs at 8 month old. She has the same structure as your son. When I look at her her bones seem very thin and long... I don't know how to explain it but she is thin and long. She has severa gastric emptying delay 177mn and very mild cerebral palsy. It's just now at 22month old that she is trying to walk. She also has sensory processing disorder but is def not autistic according to her neurologist and early intervention. Here is my email address oumou.fofana@gmail.comPlease email me. We discovered boost essential kids 1.5 and that's what helped us put her weight up.

As a general update, Alrik is 4.5 years old now and still thriving and still on the small side. He's up to the 11th percentile for weight and still in the 30s for height, with no intervention. I've been feeling confident that that's just the general size and shape of his body since he's otherwise so healthy and active and developmentally on track. He's a natural at gymnastics class since he can still literally be tossed in the air. We've since had a third boy who's built like his oldest brother and is a chunkster. It's funny that I breastfed them all, have fed them the same foods, do the same activities, and yet here they are, all firmly themselves. There's a lesson in there somewhere for us adults!

I'm so glad I came across this blog! My 2 year old son, Nathan is a skinny, energetic and intelligent toddler. Like you, I'm 90% okay with his development because he's so smart and is actually hitting all his milestones early. However, I cringe every time I see him naked because I'm so used to chubby kids in my family. That remaining 10% of my subconscious is gnawing at my heart that he might be sick or is FTT. The only problem with that last theory is that he's proven to everyone that he's in fact, a THRIVING, bright, "skinny" little boy. Blood tests that we agreed to came back normal so I've learned to somewhat accept the fact that he's just a small boy (for now). Wether he grows up to be 6 feet tall or 5'6, he'll always be my little peanut =)

@Unknown: I'm glad to hear you got reassuring results from the tests! My skinny guy is 5 now and still skinny and petite and active and healthy. I know it's not the same for everyone, but there definitely are naturally small people, and there are outliers in every family. Thanks for commenting!

I know you posted this a while ago, but I have a daughter who is now considered SGA (Small for Gestational Age), which is more or less the same thing as Failure to Thrive, but kind of a diagnosis that says she's been tested for everything and we don't know why she doesn't grow. If you haven't heard of the MAGIC Foundation any of you out there, i HIGHLY recommend checking out their organization! Also, if you have trouble finding pants for your kiddos, check out www.pantsforpeanuts.com. A start up company trying to make pants for FTT kiddos. Good luck to all of you!

@Carrie Benson: We didn't do any additional testing or interventions, and Alrik is now almost 6 and still very healthy and thin. He's on the charts now for weight and is up to about the 60th percentile for height. He's highly active and developmentally on track, so we're just letting him be skinny! Hope that helps.

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Riding the rails with my husband, Crackerdog Sam, and our hobo kids, Mikko Lint Picker (born June 2007), Alrik Irontrousers (born May 2011), and Karsten (born October 2014). Trying every day to parent intentionally and with grace.